Copy of An Integrative Approach to Complementary and Alternative Medicine in Community Settings

An Integrative Approach to Complementary and Alternative Medicine in Community Settings Maureen A. Flannery MD, MPH Department of Family Practice and Community Medicine University of Kentucky College of Medicine & WaysMeet Berea Kentucky 1 Learning Objectives • To define complementary and alternative medicine (CAM) in relationship to conventional medicine. • To discuss characteristics of CAM users and practitioners and their implications for conventional health providers. 2 Learning Objectives • To discuss issues that patient CAM use raises for conventional health providers and suggest strategies for communication with patients about CAM. • To review current evidence and research in progress about CAM modalities for common problems. 3 Learning Objectives • To describe an approach to advising patients about CAM that takes into account both evidence-based research and patient values and preferences. 4 Complementary and Alternative Medicine (CAM) • a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (1) • healing therapies that typically fall outside the Western biomedical model of disease, diagnosis, and treatment (2) (1) Eisenberg 1993; (2) Drivdahl 1998 5 Types of CAM included in national and KY surveys Acupuncture Imagery Aromatherapy Magnets Biofeedback Massage Chiropractic Prayer Diets Reflexology Exercise Relaxation Folk remedies Self-help/support groups Herbal/botanical therapySpiritual healing (by others) Homeopathy Vitamins Hypnosis Yoga 6 Major Domains of CAM • • • • Alternative medical systems Mind-body interventions Biologically-based treatments Manipulative and body-based methods • Energy therapies www.nccam.nih.gov 7 Complementary and Alternative Medicine (CAM) The list of what is considered to be CAM changes continually as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge. www.nccam.nih.gov 8 Who uses CAM? • Surveys show large increase in past 50 years in U.S. and other industrialized countries (1). • Between 1990 to 1997, increase from 34% to 42% of US households reporting CAM use (2). • In 2002, 75% of U.S. adults reported use of CAM in lifetime and 62% in past 12 months (when prayer included) (3) (1) Kessler 2001; (2) Eisenberg 1998; (3) Barnes 2004 9 Who uses CAM? 10 Who uses CAM? • Surveys of primary care clinic populations show 28-47% utilization of CAM. • 21% of patients in primary care practices reported using CAM for the same health problem for which they sought conventional care on that visit. Palinkas 2000 11 Do rural residents use CAM? • South Carolina (Oldendick 2000) 44% • Rural PA FP clinic (Del Mundo 2002) • Rural IL FP clinics (Herron 2003) • Rural MS elderly (Cuellar 2003) • Western NC (Arcury 2004) 47% 63% 49% ~50% 12 How about CAM use in Kentucky? Report of primary care clinicians in Kentucky Ambulatory Network • Patient(s) asked about CAM • Patient(s) reported CAM use • Clinician used CAM • Clinician recommended CAM KAN CAM 1 2003 86% 94% 49% 80% 13 How about CAM use in Kentucky? Pilot study of patients in Kentucky Ambulatory Network practices • KAN CAM 2 2004 14 Who uses CAM? • Chiropractic and massage are most frequently used practitioner-based CAM therapies (1). – An estimated 8-17% of US population visits a chiropractor each year, 33% over lifetime. – About 1/3 of US population reports having ever had a therapeutic massage. • Individuals in rural and underserved communities are particularly likely to use chiropractic care (2). 15 How about CAM use in Kentucky? Pilot study of patients in Kentucky Ambulatory Network practices • KAN CAM 2 2004 16 Who uses CAM? • Chiropractic and massage are most frequently used practitioner-based CAM therapies (1). – An estimated 8-17% of US population visits a chiropractor each year, 33% over lifetime. – About 1/3 of US population reports having ever had a therapeutic massage. • Individuals in rural and underserved communities are particularly likely to use chiropractic care (2). 17 Who uses CAM? • Chiropractic and massage are most frequently used practitioner-based CAM therapies (1). – An estimated 8-17% of US population visits a chiropractor each year, 33% over lifetime. – About 1/3 of US population reports having ever had a therapeutic massage. • Individuals in rural and underserved communities are particularly likely to use chiropractic care (2). 18 Who uses CAM? • Chiropractic and massage are most frequently used practitioner-based CAM therapies (1). – An estimated 8-17% of US population visits a chiropractor each year, 33% over lifetime. – About 1/3 of US population reports having ever had a therapeutic massage. • Individuals in rural and underserved communities are particularly likely to use chiropractic care (2). – Chiropractors in every zip code region in KY – 6% of massage therapists are in rural areas 19 What CAM do people use? • Chiropractic and massage are most frequently used practitioner-based CAM therapies (1). – An estimated 8-17% of US population visits a chiropractor each year, 33% over lifetime. – About 1/3 of US population reports having ever had a therapeutic massage. • Individuals in rural and underserved communities are particularly likely to use chiropractic care (2). (1) Kessler 2001; (2) Smith 2002 20 What CAM do people use? • Herbal therapy is used by 12-14% of the US population, up from 2.5% in 1990. • 16-18% of patients taking prescription medications also take herbal remedies. Kaufman 2002 21 Why do people use CAM? • • • • Desire for health and wellness (1) Prevention Cancer- recent estimate 83% (2) Pain – Musculoskeletal pain – Back and neck pain (1) Wolsko 2002 (2) NCCAM newsletter Winter 2003 22 Why do people use CAM? • Musculoskeletal pain accounted for 1/3 of CAM use among primary care patients (1). • In national household survey, 54% reported using CAM for neck or back pain in past year, compared to 37% who had seen a conventional provider for these symptoms (2). (1) Palinkas 2000; (2) Wolsko 2003 23 Why do people use CAM? • • • • Desire for health and wellness (1) Prevention Cancer- recent estimate 83% (2) Pain – Musculoskeletal pain – Back and neck pain 24 Why do people use CAM? • Very few individuals rely exclusively upon alternative modalities (1). • Most individuals who use CAM do so because of preference and the perception that the combination of CAM and conventional treatments is superior to either alone (2). (1) Astin 1998; (2) Eisenberg 2001 25 Why do people use CAM? Patients use CAM • • when it is consistent with their worldview and when conventional care is not relieving their symptoms. Testerman 2004 26 What do CAM users want? • Empowerment in medical interactions • Chance to share their own views about health and healing • Health provider who will spend time with them • Someone who will answer their questions Weil 2000 27 What do CAM users want? • Empowerment in medical interactions • Chance to share their own views about health and healing • Health provider who will spend time with them • Someone who will answer their questions 28 Who practices CAM? • Wide variation in background and approach • Diversity in training programs – Some weekend and/or distance learning certificate programs – Non-MD acupuncture programs require 2,000-3,000 hours (4 year masters degree) – Chiropractic training involves 4 years beyond 2 or 4 years of college • No standardization of approach to accreditation and licensure – Most require 300-500 hours and CEUs • Variations by type of practitioner and by state Barrett 2000, Eisenberg 2002 29 Who practices CAM? • Chiropractors – Around 66,000 DCs in US (over 600 in KY) – Most accepted professional therapy – Licensed in all states – High patient satisfaction Massage Therapists – Over 46,000 AMTA members in US – Most common CAM modality in hospitalbased programs – Licensed in 2/3 of states (KY in 2003) 30 • Who practices CAM? • Increasing numbers of dual-trained practitioners • RNs – Holistic Nursing Certification – Therapeutic Touch, Healing Touch • MDs and DOs – American Board of Holistic Medicine – American Board of Medical Acupuncture 31 Who practices CAM? How did I get to be a ―dual-trained MD‖? www.waysmeet.net 32 What about communication? • Between 40 and 70% of CAM users do not disclose their use to their physician. WHY? • Patients usually say that they do not report because they are not asked. Eisenberg 2001 33 Why does this matter? • The substantial overlap between use of prescription medications and herbal supplements raises concerns about unintended interactions. • Patient use of CAM is often a clue to values and preferences that need to be acknowledged. Kaufman 2002 34 How can we communicate? 1. Always ask! ―What else are you doing for your health?‖ 2. Be open and nonjudgmental. 3. Consider patient preferences and values. 4. Encourage self-monitoring of results. Eisenberg 1997 35 How can we communicate? 5. Coordinate care as appropriate. 6. Be honest about your lack of knowledge and open to education. 7. Monitor safety and efficacy, arrange follow-up. 8. Document all discussions and advice. Eisenberg 1997 36 Evidence-based Medicine (EBM) and CAM EBM aims to integrate – best research evidence – clinical expertise – patient values Sackett 2000 37 EBM and CAM While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies— questions such as whether they are safe and whether they work for the diseases or medical conditions for which they are used. 38 Where are we now? There is an urgent need for more and better trials of CAM therapies! Research funding • • FY 1992 OAM $2 M FY 2004 – NCCAM $117.7 M – Total NIH funding for CAM www.nccam.nih.gov $273.4 M 39 Where does this leave us? Many conventional treatments • have been adopted without good quality research • are costly • are invasive • are likely to have adverse effects AND • often provide inadequate relief. 40 Where does this leave us? CAM interventions generally • are low cost • are low risk • are free of serious side effects AND • are widely used. 41 42 CAM: evidence and research Some common conditions • • • • • • Low back pain Osteoarthritis Headaches Migraines Fibromyalgia Cancer-related symptoms 43 CAM: evidence and research Low Back Pain Current evidence for Acupuncture Massage Spinal manipulation – acute>chronic Stress management Cherkin 2001; Ernst 2001; Furlan 2002; Astin 2004 • • • • 44 CAM: evidence and research Low Back Pain • • • Research in progress on Acupuncture Yoga, exercise, and self-care education Usual care vs alternatives – Acupuncture – Massage – Chiropractic www.nccam.nih.gov/clinicaltrials 45 CAM: evidence and research Osteoarthritis Current evidence for • • • • • Acupuncture Exercise Herbal medicine (devil’s claw, willow bark) Homeopathy Supplements (glucosamine, chondroitin) Ernst 2001 46 CAM: evidence and research Osteoarthritis Research in progress on • Efficacy of glucosamine and/or chondroitin – NIH-GAIT www.nihgait.org • Acupuncture – With brain imaging – And/or physical therapy – With different models for patient/practitioner interaction www.nccam.nih.gov/clinicaltrials 47 CAM: evidence and research Headaches Current evidence for • • • • • • • Acupuncture Autogenic training Biofeedback (muscle) Herbal medicine (topical peppermint) Hypnotherapy Relaxation Spinal manipulation Ernst 2001; Astin 2004; Vickers 2004 48 CAM: evidence and research Headaches Research in progress on • • • • Acupuncture Behavioral approaches Herbal medicine (feverfew for prevention) Massage (neck and shoulder) 49 CAM: evidence and research Migraines Current evidence for • • • • • • Acupuncture Biofeedback (thermal) Diet (avoidance of triggers) Herbal medicine (feverfew) Relaxation (adults) Supplements (magnesium, riboflavin) Ernst 2001; Mauskop 2001; Astin 2004; Vickers 2004 50 CAM: evidence and research Migraines Research in progress on • • • • Acupuncture Butterbur root extract Magnesium (oral, intravenous) Melatonin 51 CAM: evidence and research Fibromyalgia Current evidence for • • • • • • • Acupuncture Biofeedback Exercise Herbal medicine (capsaicin topical) Homeopathy Massage Meditation (TM, mindfulness) Ernst 2001; Hadhazy 2000 52 CAM: evidence and research Fibromyalgia Research in progress on • • • • • Acupuncture Homeopathy Intravenous micronutrient therapy (IVMT) Multiple component mind-body therapy (including Qi Gong) Reiki www.nccam.nih.gov/clinicaltrials 53 CAM: evidence and research Cancer-related symptoms Current evidence for • Nausea related to chemotherapy – Acupuncture – Acupressure – Herbal medicine (ginger, peppermint) – Music Ernst 2001; Weiger 2002 54 CAM: evidence and research Cancer-related symptoms Current evidence for • Pain – Acupuncture – Massage • Anxiety/depression – Massage – Mind-body approaches Ernst 2001; Weiger 2002 55 CAM: evidence and research Cancer-related symptoms • • • Research in progress on Nausea related to chemotherapy – Acupuncture – Ginger Pain and end-of-life symptoms – Massage – Acupuncture (advanced colorectal ca) Fatigue – L-carnitine – Massage www.nccam.nih.gov/clinicaltrials 56 CAM: evidence and research Cancer-related symptoms • Research in progress on Quality of life – Distant healing (glioblastoma) – Mindfulness-based art therapy – Healing touch (advanced cervical) • Lymphedema – Massage, manual lymph drainage (breast cancer) www.nccam.nih.gov/clinicaltrials 57 Framework for approaching CAM in clinical situations • • • • Protect against dangerous practices. Permit practices that are harmless and that may help. Promote and use practices that are safe and effective. Partner with patients and encourage communication about CAM. Jonas 2000 58 First, PROTECT! • Assure that an adequate diagnostic evaluation has been performed • Be certain that no contraindications to exist • Assess the safety of the CAM modality 59 Framework for approaching CAM in clinical situations • Protect against dangerous practices. • Permit practices that are harmless and that may help. • • Promote and use practices that are safe and effective. Partner with patients and encourage communication about CAM. Jonas 2000 60 Framework for approaching CAM in clinical situations Question: Is “permit” the right word here? Do health professionals have the power to ―permit‖ practices that their patients choose? 61 If your decision (for this individual patient) is to PERMIT, • Document the patient’s decision in the chart • Observe for changes that indicate a need for re-evaluation • Monitor for adverse effects • Assist the patient in evaluating outcomes 62 Framework for approaching CAM in clinical situations • • Protect against dangerous practices. Permit practices that are harmless and that may help. • Promote and use practices that are safe and effective. • Partner with patients and encourage communication about CAM. Jonas 2000 63 Is this a treatment you wish to PROMOTE for other patients? • • Good evidence for safety and efficacy Knowledge of credentials of CAM practitioner and/or Confidence in quality of product • 64 Framework for approaching CAM in clinical situations • • • Protect against dangerous practices. Permit practices that are harmless and that may help. Promote and use practices that are safe and effective. • Partner with patients and encourage communication about CAM. Jonas 2000 65 PARTNER with patients and communicate about CAM • • ASK! ALWAYS! “Build” a history that includes CAM use. (Don’t “take” one.) When patients tell, LISTEN! • Haidet 2003 66 Evidence-based Medicine (EBM) and CAM EBM aims to integrate – best research evidence – clinical expertise – patient values Sackett 2000 67 Integrative Medicine is a combination of mainstream medical therapies and CAM therapies for which there is high-quality scientific evidence of safety and effectiveness. NCCAM 2003 68 An Integrative Approach to Complementary and Alternative Medicine in Community Settings Maureen A. Flannery MD, MPH Department of Family Practice and Community Medicine University of Kentucky College of Medicine & WaysMeet Berea Kentucky 69